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INTRODUCTION: Ultrasound-guided (Echo-AVP) and Fluoroscopy-guided Axillary Vein Puncture (Fluoro-AVP) are both acknowledged as safe and effective techniques for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. Therefore, we performed a meta-analysis to evaluate the efficacy and safety of Echo-AVP versus Fluoro-AVP for CIEDs implantation. METHODS: We systematically searched Medline, Embase and Cochrane electronic databases up to May 15th, 2024, for studies that evaluated the efficacy and safety of Echo-AVP and Fluoro-AVP reporting at least one clinical outcome of interest. The primary efficacy endpoint was acute procedural success and the primary safety endpoint was a composite endpoint of pneumothorax, pocket hematoma/bleeding, pocket infection and inadvertent arterial puncture. The effect size was estimated using a random-effect model as Odds Ratio (OR) and Mean Difference (MD) with relative 95% Confidence Interval (CI). RESULTS: Overall, 4 studies were included, which enrolled 1257 patients (Echo-AVP: 373 patients; Fluoro-AVP: 884 patients). Echo-AVP led to a significant reduction in the primary safety endpoint (OR: 0.41; p = 0.0009), risk of inadvertent arterial puncture (OR: 0.29; p = 0.003) and fluoroscopy time ( MD: -105.02; p = 0.008). No differences were found between Echo-AVP and Fluoro-AVP for acute procedural success (OR: 0.77; p = 0.27), pneumothorax (OR: 0.66; p = 0.60), pocket hematoma/bleeding (OR: 0.68; p = 0.30), pocket infection (OR: 0.66; p = 0.60), procedural time (MD: 1.99; p = 0.65), success rate at first attempt (OR: 1.25; p = 0.34) and venous access time (MD: -0. 25; p = 0.99). CONCLUSION: Echo-AVP proved to reduce significantly the primary safety endpoint, inadvertent arterial puncture and fluoroscopy time compared to Fluoro-AVP.
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AIMS: Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via a pentaspline pulsed field ablation (PFA) catheter in persistent AF sustained beyond 6 months (PerAF > 6â m) and long-standing persistent AF (LSPAF). METHODS AND RESULTS: The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia regionalization and ablation (Stage 3). Seventy-two [age:68 ± 10years, 61.1%males; AF history: 25 (18-45) months] patients with PerAF > 6â m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The PFA catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit. Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112 ± 25â min and 59 ± 22â min, respectively. Major complications occurred in 2 (2.8%) patients. Single-procedure success rate was 74.6% after 14.9 ± 2.7 months of follow-up; AF-free survival was 89.2%. CONCLUSION: In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favourable clinical outcomes were observed during >1 year of follow-up.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Electrophysiologic Techniques, Cardiac , Atrial Fibrillation/surgery , Atrial Fibrillation/physiopathology , Atrial Fibrillation/diagnosis , Humans , Male , Catheter Ablation/methods , Female , Aged , Middle Aged , Pulmonary Veins/surgery , Treatment Outcome , Recurrence , Time Factors , Cardiac Catheters , Heart Rate , Action PotentialsABSTRACT
BACKGROUND: Pulsed field ablation (PFA) is a novel technology for catheter-based atrial arrhythmia treatment. Evidence of its application for ventricular arrhythmia ablation is still limited. In this study, we describe the feasibility and efficacy of focal PFA for premature ventricular contraction (PVC) ablation. METHODS: A prospective cohort of 20 patients referred for PVC ablation at 2 centers was enrolled, regardless of the presence of structural heart disease, PVC morphology, or previous ablation attempts. All procedures were performed using the CENTAURI System in combination with contact force sensing catheters and 3-dimensional electroanatomical mapping systems. Energy output and the number of applications were left to the operator's discretion. RESULTS: Eleven (55%) procedures were conducted under general anesthesia, 6 (30%) under deep sedation, and 3 (15%) under light sedation. Muscular contraction was observed in one case (5%). Median procedural and fluoroscopy times were 95.5 and 6.55 minutes, respectively. The median number of PFA applications was 8 with a median contact force of 10g. A statistically significant (76%) reduction was observed in mean peak-to-peak bipolar electrogram voltage before and after ablation (0.707 versus 0.098 mV; P=0.008). Ventricular irritative firing was observed in 11 (55%) patients after PFA. The median follow-up was 120 days. Acute procedural success was achieved in 17 of 20 (85% [95% CI, 0.70-1]) patients. Two of the patients with procedural failure had late success with >80% clinical PVC burden suppression during follow-up, and 2 of 17 patients with acute success had late PVC recurrence, which accounts for a total of 17 of 20 (85% [95% CI, 0.70-1]) patients with chronic success. Transient ST-segment depression occurred in 1 patient, and the right bundle branch block was induced in 2 others (permanently only in one case). CONCLUSIONS: PVC ablation using a focal PFA is feasible, effective, and safe, with promising acute and long-term results in several ventricular locations. Irritative firing is frequently observed. Coronary evaluation should be considered when targeting the outflow tract.
Subject(s)
Catheter Ablation , Feasibility Studies , Ventricular Premature Complexes , Humans , Ventricular Premature Complexes/physiopathology , Ventricular Premature Complexes/surgery , Ventricular Premature Complexes/diagnosis , Male , Female , Middle Aged , Prospective Studies , Treatment Outcome , Catheter Ablation/methods , Aged , Electrophysiologic Techniques, Cardiac , Time Factors , Adult , Action Potentials , Heart RateABSTRACT
INTRODUCTION: Thermal atrial fibrillation (AF) ablation exerts an additive treatment effect on the cardiac autonomic nervous system (CANS). This effect is mainly reported during ablation of the right superior pulmonary vein (RSPV), modulating the right anterior ganglionated plexus (RAGP), which contains parasympathetic innervation to the sinoatrial node in the epicardial fat pad between RSPV and superior vena cava (SVC). However, a variable response to neuromodulation after ablation is observed, with little to no effect in some patients. Our objective was to assess clinical and anatomic predictors of thermal ablation-induced CANS changes, as assessed via variations in heart rate (HR) postablation. METHODS: Consecutive paroxysmal AF patients undergoing first-time PV isolation by the cryoballoon (CB) or radiofrequency balloon (RFB) within a 12-month time frame and with preprocedural cardiac computed tomography (CT), were evaluated. Preablation and 24-h postablation electrocardiograms in sinus rhythm were collected and analyzed to assess HR. Anatomic evaluation by CT included the measurement of the shortest distance between the SVC and RSPV ostium (RSPV-SVC distance). RESULTS: A total of 97 patients (CB, n = 50 vs. RFB, n = 47) were included, with similar baseline characteristics between both groups. A significant HR increase postablation (ΔHR ≥ 15 bpm) occurred in a total of 37 patients (38.1%), without difference in number of patients between both thermal ablation technologies (CB, 19 [51%]), RFB, 18 [49%]). Independent predictors for increased HR were RSPV-SVC distance (odds ratio [OR]: 0.49, CI: 0.34-0.71, p value < .001), and age (OR: 0.94, CI: 0.89-0.98, p value = .003). CONCLUSIONS: Thermal balloon-based PV isolation influences the CANS through its effect on the RAGP, especially in younger patients and patients with shorter RSPV-SVC distance.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Cryosurgery , Heart Rate , Pulmonary Veins , Humans , Atrial Fibrillation/surgery , Atrial Fibrillation/physiopathology , Atrial Fibrillation/diagnosis , Female , Male , Middle Aged , Aged , Treatment Outcome , Pulmonary Veins/surgery , Pulmonary Veins/physiopathology , Cryosurgery/adverse effects , Catheter Ablation/adverse effects , Time Factors , Action Potentials , Vena Cava, Superior/surgery , Vena Cava, Superior/physiopathology , Autonomic Nervous System/physiopathology , Autonomic Nervous System/surgery , Retrospective Studies , Risk FactorsSubject(s)
Catheter Ablation , Coronary Vasospasm , Humans , Catheter Ablation/adverse effects , Coronary Vasospasm/physiopathology , Coronary Vasospasm/etiology , Coronary Vasospasm/diagnostic imaging , Coronary Vasospasm/diagnosis , Male , Coronary Angiography , Treatment Outcome , Middle Aged , Atrial Fibrillation/surgery , Atrial Fibrillation/physiopathology , Atrial Fibrillation/diagnosis , Female , Cardiac CathetersABSTRACT
BACKGROUND: Brugada Syndrome (BrS) is a life-threatening cardiac arrhythmia disorder associated with an increased risk ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Current management primarily relies on implantable cardioverter-defibrillators (ICDs), but patients may experience ICD shocks. Catheter ablation (CA) has emerged as a potential intervention to target the arrhythmogenic substrate. This systematic review aims to evaluate the safety and efficacy of catheter ablation in BrS patients. METHODS AND RESULTS: Studies with BrS patients undergoing catheter ablation for VAs were included. 14 studies that involved a total population of 709 BrS patients, with catheter ablation performed in 528 of them, were included. Catheter ablation resulted in non-inducibility of VAs in 91% (95% CI: 83-99, I2 = 76%) and resolution of Type 1 ECG Brugada pattern in 88% (95% CI: 81-96.2, I2 = 91%) of the patients. After a mean follow-up of 30.7 months, 87% (95% CI: 80-94, I2 = 82%) of patients remained free from VAs. The incidence of VAs during follow-up was significantly lower in the ablation cohort in comparison to the group receiving only ICD therapy (OR = 0.03, 95% CI: 0.01-0.12, I2 = 0%). CONCLUSION: Catheter ablation shows potential as a therapeutic approach to reduce VAs and improve outcomes in BrS patients. While further research with long follow-up period is required to confirm these findings, it represents a valuable tool as an add-on intervention to ICD implantation in BrS patients with high burden of VAs.Protocol registration: CRD42024506439.
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BACKGROUND: Brugada syndrome (BrS) has been associated with sudden cardiac death in otherwise healthy subjects, and drug-induced BrS accounts for 55% to 70% of all patients with BrS. This study aims to develop a deep convolutional neural network and evaluate its performance in recognizing and predicting BrS diagnosis. METHODS AND RESULTS: Consecutive patients who underwent ajmaline testing for BrS following a standardized protocol were included. ECG tracings from baseline and during ajmaline were transformed using wavelet analysis and a deep convolutional neural network was separately trained to (1) recognize and (2) predict BrS type I pattern. The resultant networks are referred to as BrS-Net. A total of 1188 patients were included, of which 361 (30.3%) patients developed BrS type I pattern during ajmaline infusion. When trained and evaluated on ECG tracings during ajmaline, BrS-Net recognized a BrS type I pattern with an AUC-ROC of 0.945 (0.921-0.969) and an AUC-PR of 0.892 (0.815-0.939). When trained and evaluated on ECG tracings at baseline, BrS-Net predicted a BrS type I pattern during ajmaline with an AUC-ROC of 0.805 (0.845-0.736) and an AUC-PR of 0.605 (0.460-0.664). CONCLUSIONS: BrS-Net, a deep convolutional neural network, can identify BrS type I pattern with high performance. BrS-Net can predict from baseline ECG the development of a BrS type I pattern after ajmaline with good performance in an unselected population.
Subject(s)
Ajmaline , Brugada Syndrome , Deep Learning , Electrocardiography , Humans , Brugada Syndrome/diagnosis , Brugada Syndrome/physiopathology , Brugada Syndrome/chemically induced , Electrocardiography/drug effects , Male , Female , Ajmaline/adverse effects , Middle Aged , Adult , Predictive Value of Tests , Retrospective StudiesABSTRACT
BACKGROUND: A rare gene variant in SCN5A can be found in approximately 20%-25% of patients with Brugada syndrome (BrS). OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the differences in clinical characteristics of BrS patients with and without SCN5A rare variants and the prognostic role of SCN5A for ventricular arrhythmias in BrS. METHODS: PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched from inception to January 2024 to identify all relevant studies. Studies were analyzed if they included patients diagnosed with BrS in whom genetic testing for SCN5A variants was performed and arrhythmic outcomes were reported. RESULTS: A total of 17 studies with 3568 BrS patients, of whom 3030 underwent genetic testing for SCN5A variants, fulfilled the eligibility criteria and were included. Compared with SCN5A- patients, SCN5A+ BrS patients more frequently had spontaneous type 1 electrocardiogram, history of syncope, and documented arrhythmias. Furthermore, higher PQ and QRS intervals in SCN5A+ BrS patients compared with SCN5A- have been found. The pooled analysis demonstrated a significant association between the presence of SCN5A rare variants in BrS patients and the risk of major arrhythmic events, with a pooled odds ratio of 2.14 (95% confidence interval, 1.53-2.99; I2 = 29%). CONCLUSION: SCN5A+ BrS patients showed a worse clinical phenotype compared with SCN5A-. The pooled analysis demonstrated a significant association between SCN5A+ mutation status and the risk of major arrhythmic events in BrS patients.
Subject(s)
Brugada Syndrome , NAV1.5 Voltage-Gated Sodium Channel , Brugada Syndrome/genetics , Brugada Syndrome/physiopathology , Brugada Syndrome/complications , Humans , NAV1.5 Voltage-Gated Sodium Channel/genetics , Electrocardiography , Genetic Predisposition to Disease , MutationABSTRACT
Background: Pericarditis is the most common complication following hybrid sinus node-sparing ablation for inappropriate sinus tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS). Objective: The study sought to evaluate the association of prophylaxis therapy on the risk of symptomatic pericarditis following hybrid IST/POTS ablation. Methods: All consecutive patients undergoing to hybrid ablation of symptomatic IST/POTS refractory or intolerant to drugs were retrospectively analyzed. Pharmacological prophylaxis therapy was based on acetylsalicylic acid and colchicine started on the day of the ablation and continued for at least 3 months. The primary endpoint was occurrence of symptomatic pericarditis. The secondary endpoint was occurrence of pericarditis-related complications, including the following: duration of pericarditis >3 months, hospitalization for pericarditis, postpericardiectomy pleuro-pericarditis, and pericardiectomy. Results: A total of 220 patients undergone to hybrid IST/POTS ablation were included and 44 (20%) underwent prophylaxis therapy. Pericarditis occurred in 101 (45.9%) patients, with 97 (96%) in the first 5 days. At survival analysis, prophylaxis was associated with higher rate of freedom from pericarditis (81.9% vs 47.2%, log-rank P < .001). Pericarditis-related complications were low, occurring in 7 (3.2%) patients. There was no difference in pericarditis-related complications between the patients who underwent prophylaxis therapy and patients who did not. At Cox multivariate analysis, predictors of pericarditis were IST (vs POTS) (hazard ratio 0.61, 95% confidence interval0.39-0.99, P = .04) and prophylaxis therapy (hazard ratio 0.27, 95% confidence interval 0.13-0.55, P < .001). Conclusion: In a large cohort of patients undergoing hybrid ablation for IST/POTS, a prophylaxis therapy with acetylsalicylic acid and colchicine was associated with a lower rate of symptomatic pericarditis.
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BACKGROUND: A pathogenic/likely pathogenic variant can be found in 20% to 25% of patients with Brugada syndrome (BrS) and a pathogenic/likely pathogenic variant in SCN5A is associated with a worse prognosis. The aim of this study is to define the diagnostic yield of a large gene panel with American College of Medical Genetics and Genomics variant classification and to assess prognosis of SCN5A and non-SCN5A variants. METHODS: All patients with BrS, were prospectively enrolled in the Universitair Ziekenhuis Brussel registry between 1992 and 2022. Inclusion criteria for the study were (1) BrS diagnosis; (2) genetic analysis performed with a large gene panel; (3) classification of variants following American College of Medical Genetics and Genomics guidelines. Patients with a pathogenic/likely pathogenic variant in SCN5A were defined as SCN5A+. Patients with a reported variant in a non-SCN5A gene or with no reported variants were defined as patients with SCN5A-. All variants were classified as missense or predicted loss of function. RESULTS: A total of 500 BrS patients were analyzed. A total of 104 patients (20.8%) were SCN5A+ and 396 patients (79.2%) were SCN5A-. A non-SCN5A gene variant was found in 75 patients (15.0%), of whom, 58 patients (77.3%) had a missense variant and 17 patients (22.7%) had a predicted loss of function variant. At a follow-up of 84.0 months, 48 patients (9.6%) experienced a ventricular arrhythmia (VA). Patients without any variant had higher VA-free survival, compared with carriers of a predicted loss of function variant in SCN5A+ or non-SCN5A genes. There was no difference in VA-free survival between patients without any variant and missense variant carriers in SCN5A+ or non-SCN5A genes. At Cox analysis, SCN5A+ or non-SCN5A predicted loss of function variant was an independent predictor of VA. CONCLUSIONS: In a large BrS cohort, the yield for SCN5A+ is 20.8%. A predicted loss of function variant carrier is an independent predictor of VA.
Subject(s)
Brugada Syndrome , Humans , Brugada Syndrome/diagnosis , Brugada Syndrome/genetics , Genetic Testing , Arrhythmias, Cardiac/genetics , Mutation, Missense , NAV1.5 Voltage-Gated Sodium Channel/genetics , MutationABSTRACT
BACKGROUND: Pulsed field ablation (PFA) is selective for the myocardium. However, vagal responses and reversible effects on ganglionated plexi (GP) are observed during pulmonary vein isolation (PVI). Anterior-right GP ablation has been proven to effectively prevent vagal responses during radiofrequency-based PVI. OBJECTIVE: The purpose of this study was to test the hypothesis that PFA-induced transient anterior-right GP modulation when targeting the right superior pulmonary vein (RSPV) before any other pulmonary veins (PVs) may effectively prevent intraprocedural vagal responses. METHODS: Eighty consecutive paroxysmal atrial fibrillation patients undergoing PVI with PFA were prospectively included. In the first 40 patients, PVI was performed first targeting the left superior pulmonary vein (LSPV-first group). In the last 40 patients, RSPV was targeted first, followed by left PVs and right inferior PV (RSPV-first group). Heart rate (HR) and extracardiac vagal stimulation (ECVS) were evaluated at baseline, during PVI, and postablation to assess GP modulation. RESULTS: Vagal responses occurred in 31 patients (78%) in the LSPV-first group and 5 (13%) in the RSPV-first group (P <.001). Temporary pacing was needed in 14 patients (35%) in the LSPV-first group and 3 (8%) in the RSPV-first group (P = .003). RSPV isolation was associated with similar acute HR increase in the 2 groups (13 ± 11 bpm vs 15 ± 12 bpm; P = .3). No significant residual changes in HR or ECVS response were documented in both groups at the end of the procedure compared to baseline (all P >.05). CONCLUSION: PVI with PFA frequently induced vagal responses when initiated from the LSPV. Nevertheless, an RSPV-first approach promoted transient HR increase and reduced vagal response occurrence.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Heart Rate , Pulmonary Veins , Vagus Nerve , Humans , Pulmonary Veins/surgery , Atrial Fibrillation/surgery , Atrial Fibrillation/physiopathology , Male , Female , Catheter Ablation/methods , Middle Aged , Heart Rate/physiology , Vagus Nerve/physiopathology , Vagus Nerve/physiology , Prospective Studies , Heart Conduction System/physiopathology , Aged , Treatment Outcome , Ganglia, Autonomic/physiopathology , Ganglia, Autonomic/surgery , Follow-Up StudiesABSTRACT
BACKGROUND: Posterior wall (PW) isolation is an important adjunctive ablation target in patients with non-paroxysmal atrial fibrillation (AF). Traditionally performed with point-by-point radiofrequency (RF) ablation, PW isolation has also been performed with different cryoballoon technologies. We aimed at assessing the feasibility of PW isolation with the novel RF balloon catheter Heliostar™ (Biosense Webster, CA, USA). METHODS: We prospectively enrolled 32 consecutive patients with persistent AF scheduled for first-time ablation with the Heliostar™ device. Procedural data were compared with those from 96 consecutive persistent AF patients undergoing pulmonary vein (PV) plus PW isolation with a cryoballoon device. The ratio RF balloon/cryoballoon was 1:3 for each operator involved in the study, aiming at avoiding any imbalance related to different experience. RESULTS: Single-shot PV isolation was documented in a significantly higher number of cases with the RF balloon technology compared to cryoballoon ablation (89.8% vs. 81.0%; p = 0.02, respectively). PW isolation was achieved with a similar number of balloon applications between the two groups (11 ± 4 with the RF balloon versus 11 ± 2 with the cryoballoon; p = 0.16), but in a significantly shorter time among RF balloon patients (228 ± 72 s versus 1274 ± 277 s with cryoballoon; p < 0.001). Primary safety endpoint occurred in none of the RF balloon patients versus 5 (5.2%) patients in the cryoballoon group (p = 0.33). Primary efficacy endpoint was achieved in all (100%) RF balloon patients versus 93 (96.9%) cryoballoon ones (p = 0.57). Oesophageal endoscopy did not show any signs of thermal lesions in RF balloon patients with luminal temperature rise. CONCLUSIONS: RF balloon-based PW isolation was safe and promoted shorter procedure times compared to similar cryoballoon-based ablation procedures.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Cryosurgery , Pulmonary Veins , Humans , Cryosurgery/methods , Feasibility Studies , Treatment Outcome , Catheter Ablation/methods , Recurrence , Atrial Fibrillation/diagnostic imaging , Atrial Fibrillation/surgery , Pulmonary Veins/surgery , CathetersABSTRACT
AIMS: Catheter ablation (CA) is an established treatment for atrial fibrillation (AF). A computed tomography (CT) may be performed before ablation to evaluate the anatomy of pulmonary veins. The aim of this study is to investigate the prevalence of patients with coronary artery disease (CAD) detected by cardiac CT scan pre-ablation and to evaluate the impact of CAD and revascularization on outcomes after AF ablation. METHODS AND RESULTS: All consecutive patients with AF diagnosis, hospitalized at Universitair Ziekenhuis Brussel, Belgium, between 2015 and 2019, were prospectively screened for enrolment in the study. Inclusion criteria were (i) AF diagnosis, (ii) first procedure of AF ablation with cryoballoon CA, and (iii) contrast CT scan performed pre-ablation. A total of 576 consecutive patients were prospectively included and analysed in this study. At CT scan, 122 patients (21.2%) were diagnosed with CAD, of whom 41 patients (7.1%) with critical CAD. At survival analysis, critical CAD at CT scan was a predictor of atrial tachyarrhythmia (AT) recurrence during the follow-up, only in Cox univariate analysis [hazard ratio (HR) = 1.79] but was not an independent predictor in Cox multivariate analysis. At Cox multivariate analysis, independent predictors of AT recurrence were as follows: persistent AF (HR = 2.93) and left atrium volume index (HR = 1.04). CONCLUSION: In patients undergoing CT scan before AF ablation, critical CAD was diagnosed in 7.1% of patients. Coronary artery disease and revascularization were not independent predictors of recurrence; thus, in this patient population, AF ablation should not be denied and can be performed together with CAD treatment.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Coronary Artery Disease , Pulmonary Veins , Humans , Atrial Fibrillation/diagnosis , Atrial Fibrillation/epidemiology , Atrial Fibrillation/surgery , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/epidemiology , Coronary Artery Disease/surgery , Treatment Outcome , Heart Atria , Catheter Ablation/adverse effects , Catheter Ablation/methods , Pulmonary Veins/diagnostic imaging , Pulmonary Veins/surgery , RecurrenceABSTRACT
AIMS: A novel sinus node (SN) sparing hybrid ablation for inappropriate sinus node tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS) has been demonstrated to be an effective and safe therapeutic option in patients with symptomatic drug-resistant IST/POTS. The aim of this study was to evaluate the long-term rate of redo procedures after hybrid IST ablation and procedural strategy, outcomes and safety of redo procedures. METHODS AND RESULTS: All consecutive patients from 2015 to 2023 were prospectively enrolled in the UZ Brussel monocentric IST/POTS registry. They were analysed if the following inclusion criteria were fulfilled: 1) diagnosis of IST or POTS, 2) symptomatic IST/POTS refractory or intolerant to drugs, and 3) hybrid SN sparing ablation performed. The primary endpoint was redo procedure. The primary safety endpoint was pacemaker (PM) implantation. A total of 220 patients undergone to hybrid IST ablation were included, 185 patients (84.1%) were treated for IST and 61 patients (27.7%) for POTS.After a follow-up of 73.3 ± 16.2 months, 34 patients (15.4%) underwent a redo. A total of 23 patients (67.6%) had a redo for IST recurrence and 11 patients (32.4%) for other arrhythmias. Pacemaker implantation was performed in 21 patients (9.5%). Nine patients (4.1%) had no redo procedure and experienced sick sinus syndrome requiring a PM. Twelve patients (5.4%) received a PM as a shared therapeutic choice combined with SN ablation procedure. CONCLUSION: In a large cohort of patients the long-term free survival from redo procedure after hybrid IST ablation was 84.6% with a low PM implantation rate.
Subject(s)
Catheter Ablation , Tachycardia, Sinus , Humans , Tachycardia, Sinus/diagnosis , Tachycardia, Sinus/surgery , Tachycardia, Sinus/drug therapy , Sinoatrial Node , Catheter Ablation/adverse effects , Catheter Ablation/methods , Heart RateABSTRACT
Previous clinical studies on pulmonary vein isolation (PVI) with radiofrequency balloons (RFB) reported safe and effective procedures for a 20 s RF delivery via posterior electrodes. Recent recommendations from the manufacturer suggest reducing the application time to 15 s on the posterior wall (PW) when facing the esophagus region. Here, we retrospectively assess whether 15 s of RF delivery time on posterior electrodes is safe while still ensuring lesion metrics of sufficient quality. This retrospective study included 133 patients with paroxysmal and persistent atrial fibrillation who underwent PVI using an RFB (Heliostar, Biosense Webster, Inc., Irvine, CA, USA) at two European centers. The ablation protocol was set for an RF duration of 20 s/60 s for the posterior/anterior electrodes. A multielectrode temperature probe was systematically used. In the case of an esophageal temperature rise (ETR) above 42 °C (ETR+), an endoscopic evaluation was performed. All posterior electrode lesion metric dynamics (temperature (T) and impedance (Z)) were collected from the RFB generator and analyzed offline. In total, 2435 posterior electrode applications were analyzed. With an RF delivery of 19.8 (19.7-19.8) s, the median impedance drop was 18.4 (12.2-25.2) Ω, while the temperature rise was 11.1 (7.1-14.9) °C. Accordingly, impedance (84.6 (79.3-90.2) Ω) and temperature plateaus (38 (35.3-41.1) °C) were reached at 13.9 (10.6-16) s and 16.4 (12.6-18.5) s, respectively. Overall, 99.6% and 95.8% of electrodes reached 90% (16.6 Ω) and 95% (17.5 Ω) of their impedance drops within 15 s of RF delivery, while 97.2% and 92.8% achieved 90% (34.2 °C) and 95% (36.1 °C) of their temperature rise to reach the plateaus within 15 s of RF delivery. An ETR >42 °C occurred in 37 (30.1%) patients after 17.7 ± 2.3 s of RF delivery. In the ETR+ group, the impedance drop and temperature rise on the posterior electrodes were higher compared to patients where ETR was <42 °C. Two asymptomatic thermal esophageal injuries were observed. In conclusion, 15 s of RF delivery on the posterior electrodes provides a good balance between safety, with no esophageal temperature rise, and efficacy with high-profile lesion metrics.
ABSTRACT
INTRODUCTION: Pulmonary vein isolation (PVI) with thermal energy is characterized by concomitant ablation of the surrounding ganglionated plexi (GP). Pulsed-field ablation (PFA) selectively targets the myocardium and seems associated with only negligible effects on the autonomic nervous system (ANS). However, little is known about the dynamic effects of PFA on the GP immediately after PVI. This study sought to investigate the degree and acute vagal modulation induced by the FarapulseTM PFA system during PVI compared with single-shot thermal ablation. METHODS: A total of 76 patients underwent first-time PVI with either FarapulseTM PFA (PFA group, n = 40) or cryoballoon ablation (thermal ablation group, n = 36) for paroxysmal atrial fibrillation (AF). The effect on the ANS in the two groups was assessed before and after PVI with extracardiac vagal stimulation (ECVS). To capture any transient effects of PFA on the ANS, in a subgroup of PFA patients ECVS was repeated at three predefined timepoints: (1) before PVI (T0); (2) immediately after PVI (T1); and (3) 10 min after the last energy application (T2). RESULTS: Despite similar baseline values, the vagal response induced by ECVS after PVI almost disappeared in the thermal ablation group but persisted in the PFA group (thermal group: 840 [706-1090] ms, p < .001 compared to baseline; PFA group: 11 466 [8720-12 293] ms, p = .70 compared to baseline). Intraprocedural vagal reactions (defined as RR increase >50%, transitory asystole, or atrioventricular block) occurred more frequently with PFA than thermal ablation (70% vs. 28%, p = .001). Moreover, heart rate 24 h post-PVI increased more with thermal ablation than with PFA (16.5 ± 9.0 vs. 2.6 ± 6.1 beats/min, p < .001). In the subgroup of PFA patients undergoing repeated ANS modulation assessment (n = 11), ECVS demonstrated that PFA determined a significant acute suppression of the vagal response immediately after PVI (p < .001 compared to baseline), which recovered almost completely within 10 min. CONCLUSION: PVI with the FarapulseTM PFA system is associated with only transitory and short-lasting vagal effects on the ANS which recover almost completely within a few minutes after ablation. The impact of this phenomenon on AF outcome needs to be further investigated.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Pulmonary Veins , Humans , Pulmonary Veins/surgery , Autonomic Nervous System/surgery , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Vagus Nerve/surgery , Heart Rate , Catheter Ablation/adverse effects , Treatment OutcomeABSTRACT
AIMS: Brugada syndrome (BrS) is a hereditary arrhythmic disease, associated with sudden cardiac death. To date, little is known about the psychosocial correlates and impacts associated with this disease. The aim of this study was to assess a set of patient-reported psychosocial outcomes, to better profile these patients, and to propose a tailored psychosocial care. METHODS AND RESULTS: Patients were recruited at the European reference Centre for BrS at Universitair Ziekenhuis Brussel, Belgium. Recruitment was undertaken in two phases: phase 1 (retrospective), patients with confirmed BrS, and phase 2 (prospective), patients referred for ajmaline testing who had an either positive or negative diagnosis. BrS patients were compared to controls from the general population. Two hundred and nine questionnaires were analysed (144 retrospective and 65 prospective). Collected patient-reported outcomes were on mental health (12 item General Health Questionnaire; GHQ-12), social support (Oslo Social Support Scale), health-related quality of life, presence of Type-D personality (Type-D Scale; DS14), coping styles (Brief-COPE), and personality dimensions (Ten Item Personality Inventory). Results showed higher mental distress (GHQ-12) in BrS patients (2.53 ± 3.03) than in the general population (P < 0.001) and higher prevalence (32.7%) of Type D personality (P < 0.001) in patients with confirmed Brugada syndrome (BrS +). A strong correlation was found in the BrS + group (0.611, P < 0.001) between DS14 negative affectivity subscale and mental distress (GHQ-12). CONCLUSION: Mental distress and type D personality are significantly more common in BrS patients compared to the general population. This clearly illustrates the necessity to include mental health screening and care as standard for BrS.
Subject(s)
Brugada Syndrome , Humans , Brugada Syndrome/diagnosis , Brugada Syndrome/therapy , Brugada Syndrome/complications , Mental Health , Prospective Studies , Retrospective Studies , Quality of Life , Patient Reported Outcome Measures , Electrocardiography/methodsABSTRACT
OBJECTIVES: Brugada syndrome is a life-threatening disease with an arrhythmogenic substrate located in the epicardium of right ventricle outflow tract. Therefore, the correct region identification is crucial for a successful ablation procedure. Various mapping techniques can be adopted to elaborate this issue, but they were all initially developed for endovascular use. METHODS: In this study, we analysed 21 consecutive hybrid video-assisted thoracoscopic ablation of Brugada syndrome, performed using different mapping systems to identify the ablation target and confirm the elimination of arrhythmogenic substrate; 35 maps have been analysed. RESULTS: Acute success of epicardial right ventricle outflow tract ablation has been achieved in 100% of procedures, no periprocedural complications have been observed; HD Grid catheter showed higher area identification speed and faster fractionated potentials visualization; Rhythmia system has demonstrated the best map density; Carto 3 system showed a significant advantage in patient preparation time, but mapping speed was reduced due to focal catheter use only. CONCLUSIONS: All tested electro anatomical mapping systems can be used for hybrid video-assisted thoracoscopic ablation with same clinical success; however, accuracy and efficacy of mapping systems are heterogenous and highly dependent on proper patient preparation, mapping system and physician skills.